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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201030
Report Date: 09/25/2024
Date Signed: 09/25/2024 02:50:34 PM

Document Has Been Signed on 09/25/2024 02:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:A&A HEALTH SERVICES SAN PABLOFACILITY NUMBER:
079201030
ADMINISTRATOR/
DIRECTOR:		RIDOLFI, ELEINA LFACILITY TYPE:
735
ADDRESS:13956 SAN PABLO AVETELEPHONE:
(510) 609-4040
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 225CENSUS: 122DATE:
09/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:RAJDEEP THANDI, CHIEF COMPLIANCE OFFICERTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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On 09/25/2024 at 10:45 AM Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to conduct a case management other as a result of CCLD receiving an Unusual/Incident Report (UIR) for an incident on or around 06/29/2024. LPA met with Rajdeep Thandi, Chief Compliance Officer.

During the visit LPA attempted to interview C1, C1 refused to interview. C2 is no longer residing at the facility. LPA interviewed staff 1 and obtained the following information for C1 and C2: Admission Agreement with house rules, current Physician's Report, Behavioral Assessment, Incident reports, Case Notes, Emergency and Identification Information, Resident Roster, LIC 500, Police Report, and after visit summary for C1.


No deficiencies are cited on this date.

Exit interview conducted. A copy of this report provided to Kayla Sardenga, Operations Manager.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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